Healthcare Provider Details

I. General information

NPI: 1922834027
Provider Name (Legal Business Name): LESLY LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 N NEW YORK DR
MASSAPEQUA NY
11758-1865
US

IV. Provider business mailing address

1076 N NEW YORK DR
MASSAPEQUA NY
11758-1865
US

V. Phone/Fax

Practice location:
  • Phone: 516-776-6796
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-228694
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: